Get De2501Fc Form

The DE 2501FC form is a crucial document used to claim Paid Family Leave (PFL) Care Benefits in California. It helps individuals provide care for a family member while ensuring they receive the necessary support during this time. Understanding how to fill out this form correctly is essential for a smooth claims process.

Ready to start your claim? Fill out the DE 2501FC form by clicking the button below.

Structure

The DE 2501FC form is an essential document for individuals seeking Paid Family Leave (PFL) care benefits in California. This form is specifically designed for those who provide care for a family member with a serious health condition. To initiate the process, the care recipient must complete and sign a section of the form, known as “Part C – Statement of Care Recipient.” If the care recipient is unable to sign due to physical or mental limitations, a representative can step in, but it's important to follow the proper protocols, which may involve contacting PFL for guidance. Additionally, a licensed physician or practitioner must fill out “Part D – Physician/Practitioner’s Certification,” confirming the care recipient's condition. This certification can be done electronically through the SDI Online system or by completing the paper form. Submitting the completed forms electronically is the most efficient way to ensure timely processing, but if mailing is necessary, there are specific instructions for that as well. Each section of the DE 2501FC form is designed to gather crucial information about the care recipient, the care provider, and the medical necessity for the leave. Understanding how to correctly fill out and submit this form can significantly impact the approval and timely receipt of benefits.

De2501Fc Preview

Claim for Paid Family Leave (PFL) Care Benefits

Enter your receipt number here.

PART C – INSTRUCTIONS FOR PFL CARE CLAIMS

The care recipient (the person for whom you are providing care) must do the following: Complete and sign “Part C – Statement of Care Recipient.” If the care recipient is physically or mentally unable to sign, call PFL at 1-877-238-4373 for instructions.

The care recipient’s physician/practitioner must complete “Part D – Physician/ Practitioner’s Certification” either electronically in SDI Online, or by completing and signing page 3 of Claim for Paid Family Leave (PFL) Care Benefits (DE 2501FC). If the care recipient is under the care of an accredited religious practitioner, call PFL at 1-877-238-4373 for the proper form Practitioner’s Certification for Paid Family Leave Benefits (DE 2502F).

The easiest way to have your claim processed is to submit the completed forms electronically in SDI Online as an attachment. If submitting by mail, send to the following address: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. If submitting electronically, return to the Homepage of your SDI Online account. Select New Claim from the Menu, and select Submit Electronic Paid Family Leave Care Attachment.

PART C – STATEMENT OF		(MAY BE COMPLETED BY CLAIMANT IF CARE RECIPIENT IS MENTALLY OR PHYSICALLY UNABLE TO DO SO.
	CARE RECIPIENT	MUST BE SIGNED BY CARE RECIPIENT OR CARE RECIPIENT’S AUTHORIZED REPRESENTATIVE.)
C1.	CARE PROVIDER SSN	C2. RECIPIENT’S DATE OF BIRTH		C3. RECIPIENT’S PHONE NUMBER		C4. RECIPIENT’S GENDER
						MALE	FEMALE

C5.	LEGAL NAME OF CARE RECIPIENT (FIRST, MIDDLE INITIAL, LAST)

C6.	CARE RECIPIENT’S RESIDENCE ADDRESS
CITY		STATE/PROV.	ZIP OR POSTAL CODE		COUNTRY (IF NOT U.S.A.)

C7. CONFIRMATION OF MEDICAL DISCLOSURE AUTHORIZATION. I authorize my physician/practitioner to disclose my current personal-health information to my care provider and to the California Employment Development Department (EDD). I further understand that copies of my signature below are as valid as the original.

Care Recipient’s Signature (DO NOT PRINT)

_______________________________________________________________________________	Date Signed
C8. Authorized Representative signing on behalf of care recipient must complete the following: I,	, represent the care recipient in
this matter as authorized by parental right power of attorney (attach copy) court order (attach copy) (For spouse or domestic partner, contact EDD).
Authorized Representative’s Signature (DO NOT PRINT)
_______________________________________________________________________________	Date Signed

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Enter your receipt number here.

LEFT BLANK INTENTIONALLY

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Medical certifications must be completed by a licensed physician or practitioner authorized to certify to a patient’s disability/serious health condition pursuant to California Unemployment Insurance Code Section 2708.

Enter your receipt number here.

PART D – PHYSICIAN/PRACTITIONER’S CERTIFICATION

D1.	PFL CLAIMANT’S (CARE
	PROVIDER’S) SOCIAL
	SECURITY NUMBER		D2. PFL CLAIMANT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D3.	PATIENT’S DATE OF BIRTH		D4. DOES YOUR PATIENT REQUIRE CARE BY THE CARE PROVIDER?
			YES	NO (SKIP TO D15)

D5.	PATIENT’S NAME (FIRST, MIDDLE INITIAL, LAST)

D6.	DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS

D7.	PRIMARY ICD CODE		D8. SECONDARY ICD CODES					D9. DATE PATIENT’S CONDITION COMMENCED

			D11. DATE YOU ESTIMATE PATIENT WILL NO LONGER REQUIRE CARE BY
D10.	FIRST DATE CARE NEEDED		THE CARE PROVIDER					D12. DATE YOU EXPECT RECOVERY
					PERMANENT CARE REQUIRED			NEVER

D13.	APPROXIMATELY HOW MANY TOTAL HOURS PER DAY WILL PATIENT REQUIRE CARE BY A CARE PROVIDER?
HOURS		COMMENTS

D14.	WOULD DISCLOSURE OF THE MEDICAL INFORMATION ON THIS					D15. PHYSICIAN/		D16. STATE OR COUNTRY (IF NOT U.S.A.) IN WHICH
	CERTIFICATE BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL TO					PRACTITIONER’S		PHYSICIAN/PRACTITIONER IS LICENSED TO
	YOUR PATIENT?					LICENSE NUMBER		PRACTICE
	YES	NO

D17.	PHYSICIAN/PRACTITIONER’S NAME (FIRST, MIDDLE INITIAL, LAST)

D18.	PHYSICIAN/PRACTITIONER’S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS)
CITY			STATE/PROV.	ZIP OR POSTAL CODE			COUNTRY (IF NOT U.S.A.)

D19.	TYPE OF PHYSICIAN/PRACTITIONER					D20. SPECIALTY (IF ANY)

D21.	Physician/Practitioner’s Certification:
	I certify under penalty of perjury that this patient has a serious health condition and requires a care provider. I have performed a physical examination and/or treated
	the patient. I am authorized to certify a patient disability or serious health condition pursuant to California Unemployment Insurance Code section 2708.
	Original Signature of physician/practitioner –
	RUBBER STAMP IS NOT ACCEPTABLE
	__________________________________________________________________________
	PHYSICIAN/PRACTITIONER’S PHONE NUMBER					DATE SIGNED

Under sections 2116 and 2122 of the California Unemployment Insurance Code, it is a violation for any individual who, with intent to defraud, falsely certifies the medical condition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or a fine not exceeding $20,000. Sections 1143 and 3305 require additional administrative penalties.

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FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers on a mandatory basis to comply with California Unemployment Insurance Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.

INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information from individuals:

Agency Name:

Employment Development Department (EDD)

Title of Official Responsible for Information Maintenance:

Manager, EDD Paid Family Leave Office

Local Contact Person:

Manager, EDD Paid Family Leave Office

Address and Telephone Number:

The address and phone number of Paid Family Leave will appear on the Notice of Computation (DE 429D), issued at the time your benefit determination is made.

Maintenance of the Information is authorized by:

California Unemployment Insurance Code, sections 2601 through 3306.

California Code of Regulations, Title 22, sections 2706-1, 2706-3, 2708-1, and 2710-1.

Consequences of not providing all or any part of the requested information:

•Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits to which you are entitled.

•If you willfully make a false statement, representation, or knowingly withhold a material fact to obtain or increase any benefit or payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.

Principal purpose(s) for which the information is to be used:

•To determine eligibility for Paid Family Leave benefits.

•To be summarized and published in statistical form for the use and information of government agencies and the public. (Neither your name and identification nor the name and identification of the care recipient will appear in publications.)

•To be used to locate persons who are being sought for failure to provide child or spousal support.

•To be used by other governmental agencies to determine eligibility for public social services under the provisions of California Welfare and Institutions Code, Division 9.

•To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.

•To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section 1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the following:

(1)Administration of an unemployment insurance program.

(2)Collection of taxes which may be used to finance unemployment insurance or disability insurance.

(3)Relief of unemployed or destitute individuals.

(4)Investigation of labor law violations or allegations of unlawful employment discrimination.

(5)The hearing of workers’ compensation appeals.

(6)Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the information will be put is compatible with the purpose for which it was gathered.

(7)When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322, will be made only in those instances in which it furthers the administration of the programs mandated by that Code.

•Pursuant to California Unemployment Insurance Code, sections 1095 and 2714, information may be revealed to the extent necessary for the administration of public social services or to the Director of Social Services or his/her representatives.

•Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code, sections 1095 and 2714.

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➤ PDF File

Document Data

Fact Name	Details
Form Purpose	The DE 2501FC form is used to claim Paid Family Leave (PFL) care benefits in California.
Care Recipient's Role	The care recipient must complete and sign “Part C – Statement of Care Recipient” unless they are unable to do so.
Medical Certification	A licensed physician or practitioner must complete “Part D – Physician/Practitioner’s Certification” to validate the claim.
Submission Method	Claims can be submitted electronically through SDI Online or by mailing the form to the designated address in Sacramento, CA.
Governing Law	This form is governed by the California Unemployment Insurance Code, particularly sections 2708, 1253, and 2627.
Privacy Compliance	Disclosure of Social Security numbers is mandatory to comply with federal and state privacy laws.

How to Use De2501Fc

Filling out the DE 2501FC form is essential for initiating a claim for Paid Family Leave (PFL) Care Benefits. Follow these steps to ensure accurate completion of the form.

Enter your receipt number at the top of the form.
In Part C, have the care recipient complete and sign the “Statement of Care Recipient.” If the care recipient cannot sign, contact PFL at 1-877-238-4373 for guidance.
Ensure the care recipient’s physician or practitioner fills out “Part D – Physician/Practitioner’s Certification.” This can be done electronically in SDI Online or by signing page 3 of the DE 2501FC form.
If the care recipient is under the care of a religious practitioner, call PFL at 1-877-238-4373 to obtain the correct form (DE 2502F).
To submit electronically, log into your SDI Online account, go to the Homepage, select “New Claim” from the Menu, and choose “Submit Electronic Paid Family Leave Care Attachment.”
If mailing the form, send it to: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017.

Key Facts about De2501Fc

What is the DE 2501FC form?

The DE 2501FC form is used to claim Paid Family Leave (PFL) Care Benefits in California. This form allows individuals to request financial support while they provide care for a family member with a serious health condition. It is essential for both the care provider and the care recipient to complete specific sections of the form to ensure the claim is processed smoothly.

Who needs to sign the DE 2501FC form?

The care recipient must complete and sign “Part C – Statement of Care Recipient.” If the care recipient is unable to sign due to physical or mental limitations, the care provider may sign on their behalf. In this case, the care provider must also indicate their authority to act on the care recipient's behalf, such as through a power of attorney or court order.

What information is required from the physician or practitioner?

The physician or practitioner must fill out “Part D – Physician/Practitioner’s Certification.” This includes details about the care recipient’s condition, such as diagnosis, dates of care, and the estimated duration of care needed. The physician must also certify that the care recipient has a serious health condition that requires care. This certification is crucial for the approval of the PFL claim.

How should I submit the DE 2501FC form?

The most efficient way to submit the DE 2501FC form is electronically through the SDI Online portal. After logging in, you can attach the completed forms to your claim. If you prefer to submit by mail, send the completed form to: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. Make sure to keep a copy for your records.

What happens if I don’t provide all the required information?

Failing to provide all necessary information can lead to delays in processing your claim or even denial of benefits. It is vital to complete every section of the form accurately. If you withhold information or make false statements, you could face disqualification from receiving benefits and potential legal consequences. Ensure that all details are correct and complete before submitting your claim.

Common mistakes

When filling out the DE2501FC form for Paid Family Leave (PFL) Care Benefits, individuals often make several common mistakes that can delay processing or lead to denial of benefits. Understanding these pitfalls can help ensure a smoother application process.

One frequent error is failing to complete all required sections of the form. Each part of the DE2501FC is crucial for determining eligibility. Omitting information, such as the care recipient's legal name or Social Security number, can result in significant delays. Review the form carefully to ensure that every section is filled out completely and accurately.

Another common mistake involves incorrect signatures. The care recipient must sign the form unless they are physically or mentally unable to do so, in which case an authorized representative can sign on their behalf. It's essential that the signature matches the name provided on the form. If the care recipient is unable to sign, it’s important to follow the instructions for authorized representatives and attach the necessary documentation.

Additionally, individuals often overlook the medical certification requirements. The physician or practitioner must complete Part D of the form, which includes specific details about the patient’s condition. Failing to provide a complete certification or using an unlicensed practitioner can lead to rejection of the claim. It’s advisable to ensure that the physician is authorized to certify a patient’s serious health condition as per California regulations.

Another mistake is submitting the form via the wrong method. While electronic submission through SDI Online is preferred, some individuals still choose to mail their applications. If mailing, it is crucial to send it to the correct address: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017. Sending it to the wrong address can delay processing significantly.

People also frequently neglect to keep copies of submitted documents. Keeping a copy of the completed form and any attachments is essential for tracking the claim and addressing any future inquiries. This documentation can be helpful if there are questions about the claim or if a follow-up is necessary.

Finally, some applicants fail to double-check for accuracy before submission. Simple mistakes, such as typos in the care recipient’s information or the care provider’s Social Security number, can lead to complications. Taking the time to review the entire application can prevent unnecessary issues and ensure a smoother claims process.

Documents used along the form

When applying for Paid Family Leave (PFL) benefits, it's essential to have the right documentation in place. The DE 2501FC form is just one part of the process. Here are other important forms and documents you may need to complete your claim effectively.

DE 2502F - This form is the Practitioner’s Certification for Paid Family Leave Benefits. It must be completed by a religious practitioner if the care recipient is under their care.
DE 2501 - This is the Claim for Disability Insurance (DI) Benefits form. It is used for individuals seeking disability benefits, which can sometimes overlap with PFL claims.
DE 429D - This is the Notice of Computation, which outlines your benefit determination. It provides crucial information about your eligibility and payment amounts.
DE 2520 - The Claim for Family Leave Benefits form is needed for those applying for family leave benefits under California law. It details the reason for the leave.
DE 2580 - This form is used to request an appeal if your claim for benefits has been denied. It is crucial for ensuring you have a chance to present your case.
DE 2511 - The Request for Paid Family Leave Benefits form is used to ask for an extension or additional benefits if your initial claim is approved.
DE 2512 - This form is the Certification of Care for Family Leave Benefits. It requires the care recipient's physician to confirm the need for care.
DE 2513 - The Care Provider’s Certification form is necessary for those providing care to the recipient. It verifies the caregiver's role and responsibilities.
Power of Attorney Documents - If you are acting on behalf of the care recipient, a power of attorney document may be required to authorize your actions in the claims process.
Medical Records - Documentation from healthcare providers that outlines the care recipient's medical condition can support your claim and provide necessary context.

Having these forms ready can streamline your application process and help ensure that you receive the benefits you need without unnecessary delays. Make sure to review each document carefully and submit them as required to avoid complications.

Similar forms

DE 2501: This form is used to claim Disability Insurance (DI) benefits. Like the DE 2501FC, it requires medical certification from a physician or practitioner to validate the claimant's condition.
DE 2501F: Similar to the DE 2501FC, this form is for claiming Family Leave benefits specifically for the care of a seriously ill family member. It also requires medical documentation.
DE 2502: This document serves as a continuation of benefits for those already receiving DI. It requires updated medical information, paralleling the need for ongoing care verification in the DE 2501FC.
DE 2502F: This form is used for continuing Family Leave benefits. It shares similarities with the DE 2501FC in requiring a physician's certification for ongoing care needs.
DE 2520: This is a claim for Paid Family Leave benefits for bonding with a new child. Like the DE 2501FC, it necessitates documentation from a healthcare provider.
DE 2521: Used for claiming benefits for the care of a seriously ill child, it mirrors the DE 2501FC in terms of requiring a physician's certification.
DE 2511: This form is for reporting a change in the status of a claim. It is similar to the DE 2501FC as it requires updates on the care recipient's condition.
DE 2512: This document is used for reporting additional information related to a DI claim. It parallels the DE 2501FC in the need for accurate medical details.
DE 429D: This form provides a Notice of Computation for benefits. It is similar in purpose to the DE 2501FC, as it outlines eligibility and benefit amounts based on medical documentation.

Dos and Don'ts

When filling out the DE 2501FC form for Paid Family Leave (PFL) Care Benefits, it's important to follow specific guidelines to ensure a smooth process. Here are nine things to keep in mind:

Do complete all required sections of the form accurately.
Don't leave any fields blank unless instructed to do so.
Do ensure the care recipient signs “Part C – Statement of Care Recipient.”
Don't submit the form without the necessary physician/practitioner certification.
Do submit the completed forms electronically via SDI Online if possible.
Don't forget to include your receipt number on the form.
Do contact PFL at 1-877-238-4373 if you have questions or need assistance.
Don't use a rubber stamp for the physician/practitioner’s signature; an original signature is required.
Do send the completed form to the correct address if submitting by mail.

Following these guidelines will help ensure your claim is processed efficiently and without unnecessary delays.

Misconceptions

There are several misconceptions surrounding the DE 2501FC form, which is used for claiming Paid Family Leave (PFL) care benefits. Understanding these can help ensure that individuals complete the process correctly and efficiently.

Misconception 1: The care recipient must always sign the form themselves.

While it is preferred for the care recipient to sign the form, if they are physically or mentally unable to do so, an authorized representative can sign on their behalf. This ensures that those who cannot sign for themselves still have access to the benefits.

Misconception 2: Only physicians can complete the medical certification section.

This form requires a licensed physician or practitioner to certify the patient's condition. However, if the care recipient is under the care of an accredited religious practitioner, a different form is needed. It's important to know the correct procedures to follow in such cases.

Misconception 3: Submitting the form by mail is the only option.

In fact, the easiest way to process the claim is electronically through SDI Online. Submitting the form electronically can speed up the process and reduce the likelihood of delays.

Misconception 4: The information provided on the form is not confidential.

All information provided on the DE 2501FC form is subject to privacy regulations. The data is used solely for determining eligibility for PFL benefits and is protected under various laws to maintain confidentiality.

Misconception 5: All sections of the form are optional.

Completing all required sections of the form is crucial. Missing information can lead to delays in processing or even denial of benefits. It is essential to provide complete and accurate details to avoid complications.

Key takeaways

Here are some key takeaways about filling out and using the DE 2501FC form, which is used to claim Paid Family Leave (PFL) Care Benefits:

Care Recipient's Responsibility: The person receiving care must complete and sign “Part C – Statement of Care Recipient.” If they cannot sign due to physical or mental limitations, contact PFL for guidance.
Physician Certification: A licensed physician or practitioner must fill out “Part D – Physician/Practitioner’s Certification.” This can be done electronically or on paper.
Religious Practitioners: If the care recipient is under the care of a religious practitioner, it's necessary to call PFL for the correct certification form.
Electronic Submission: Submitting the completed forms electronically via SDI Online is the most efficient method for processing your claim.
Mailing Instructions: If you choose to mail the form, send it to the address provided: Paid Family Leave, PO Box 997017, Sacramento, CA 95899-7017.
Claimant Information: The care provider must provide their Social Security number and other identifying information in the appropriate sections of the form.
Medical Disclosure Authorization: The care recipient must authorize their physician to share their health information with both the care provider and the California Employment Development Department (EDD).
Consequences of Incomplete Information: Failing to provide all required information may delay benefit payments or result in denial of benefits.